{"id":1269,"date":"2021-08-02T11:47:50","date_gmt":"2021-08-02T09:47:50","guid":{"rendered":"https:\/\/expert.holanuna.com\/practika\/?p=1269"},"modified":"2021-08-02T11:47:50","modified_gmt":"2021-08-02T09:47:50","slug":"how-to-write-therapy-notes","status":"publish","type":"post","link":"https:\/\/expert.holanuna.com\/practika\/how-to-write-therapy-notes\/","title":{"rendered":"How to write effective therapy notes"},"content":{"rendered":"

Your last session ran over time, you\u2019ve got a pile of client emails that need an answer and you need to grab some lunch before your next appointment. You end up scribbling down some rushed therapy notes \u2013 and then spend the evening trying to remember the details (and decipher your handwriting). Sound familiar?<\/span><\/p>\n

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All therapists know how important <\/span>therapy notes<\/span> are: they act as a roadmap to keep track of your clients\u2019 progress and adjust your <\/span>treatment plan<\/span> to meet their goals.\u00a0<\/span><\/span><\/p>\n

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But all therapists also know it\u2019s hard to write <\/span>therapy notes<\/span> that capture all the required information in a concise, efficient form that won\u2019t get in the way of your schedule. This is especially true if you\u2019re trying to <\/span>start an online therapy practice.<\/span><\/a>\u00a0<\/span><\/span><\/p>\n

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Luckily, there are ways to streamline the process. In this article, <\/span>we\u2019ll show you how to write <\/b>therapy notes<\/b> that make an impact but don\u2019t eat up all your valuable time.\u00a0<\/b><\/span><\/p>\n

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We\u2019ll outline the different note types and templates available. Then, we\u2019ll give you our top recommendations for excellent <\/span>record keeping<\/span>, including <\/span>practice management software for therapists<\/span><\/a> which can save you time, keep you organized, and ensure you meet security requirements.\u00a0<\/span><\/span><\/p>\n

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Nuna is an all-in-one practice management software that lets you do it all, from scheduling appointments to doing video calls and taking <\/span><\/i>therapy notes<\/span><\/i>. <\/span><\/i>Try it now \u2013 it\u2019s free to get started.<\/span><\/i><\/a><\/span><\/p>\n

Progress notes<\/span> vs <\/span>psychotherapy notes<\/span>: What\u2019s the difference?<\/span><\/span><\/h2>\n

The two main types of therapy notes are progress notes and psychotherapy notes. They serve different purposes and are structured and written differently.<\/span><\/p>\n

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Progress notes<\/span> form part of a client\u2019s official record and may be shared with other treatment providers working with the client, or the client themselves on request. They contain <\/span>the basic details of a <\/b>therapy session<\/b>, diagnosis and assessment information, as well as clinical observations about the patient\u2019s current <\/b>mental health<\/b> and progress in their <\/b>treatment plan<\/b>.<\/b><\/span><\/p>\n

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Psychotherapy notes<\/span> are more <\/span>in-depth, <\/b>private notes<\/b> that therapists keep to log their <\/b>clinical impressions<\/b> or make detailed hypotheses<\/b> about potential issues. <\/span>Mental health professionals<\/span> often make <\/span>therapy notes<\/span> during sessions, and they usually also note down key details about the patient they can use as a memory aid for the <\/span>next session<\/span>.\u00a0<\/span><\/span><\/p>\n

 <\/p>\n\n\n\n\n\n\n\n\n
<\/td>\nProgress Notes<\/span><\/td>\nPsychotherapy notes<\/span><\/td>\n<\/tr>\n
Purpose<\/span><\/td>\n\nProvide clear official records of a patient\u2019s diagnoses, progress, and <\/span>treatment plan<\/span>.\u00a0<\/span><\/span><\/td>\n\nPrivate notes<\/span> therapists can use to inform their <\/span>treatment plan<\/span> and prepare for future sessions.\u00a0<\/span><\/span><\/td>\n<\/tr>\n
Used by<\/span><\/td>\n\nAny care provider, including medical <\/span>clinicians<\/span> and social workers.\u00a0<\/span><\/span><\/td>\n\nMental health professionals<\/span>, including psychologists, psychiatrists, and counselors.<\/span><\/span><\/td>\n<\/tr>\n
Content<\/span><\/td>\n\nTypically:\u00a0<\/span><\/p>\n
    \n
  • Medical history and diagnoses<\/span><\/li>\n
  • Prescriptions<\/span><\/li>\n
  • Treatment plan<\/span>\u00a0<\/span><\/span><\/li>\n
  • Current <\/span>presenting problem<\/span><\/span><\/li>\n
  • Other <\/span>relevant information<\/span><\/span><\/li>\n<\/ul>\n<\/td>\n
\nTypically:\u00a0<\/span><\/p>\n
    \n
  • Therapist\u2019s detailed observations and thoughts\u00a0<\/span><\/li>\n
  • Details to use as a memory aid\u00a0<\/span><\/li>\n
  • Do <\/span>not <\/b>include data on diagnoses, medical history, etc.<\/span><\/span><\/li>\n<\/ul>\n<\/td>\n<\/tr>\n
\nStyle and structure<\/span><\/td>\n\nConcise.\u00a0<\/span><\/p>\n

Highly structured.\u00a0<\/span><\/p>\n

Formal, clinical language.\u00a0<\/span><\/td>\n

\nNo fixed length.\u00a0<\/span><\/p>\n

Less structured.\u00a0<\/span><\/p>\n

Informal, personal language.<\/span><\/td>\n<\/tr>\n

\nSharing and privacy<\/span><\/td>\n\nTypically shared with:\u00a0<\/span><\/p>\n
    \n
  • Patient\u2019s other care providers.<\/span><\/li>\n
  • Third parties like <\/span>insurance companies<\/span>.\u00a0<\/span><\/span><\/li>\n
  • Patient themselves.<\/span><\/li>\n<\/ul>\n

    HIPAA<\/span>-protected and must be stored securely.<\/span><\/span><\/td>\n

\nFor the therapist\u2019s personal use \u2013 you are not required to show them to patients or others.\u00a0<\/span><\/p>\n

Must be stored securely.<\/span><\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

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7 tips on how to write <\/span>therapy progress notes<\/span><\/span><\/h2>\n

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1. Be clear, professional, and to the point.\u00a0<\/span><\/h3>\n

Remember, <\/span>progress notes<\/span> will likely be read by others who should be able to get a quick overview of the patient\u2019s history, state, and <\/span>treatment plan<\/span>.\u00a0<\/span><\/span><\/p>\n

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2. Use third-person, objective language.<\/span><\/h3>\n

As progress notes<\/span> form part of a client\u2019s healthcare record, you should write in the third person, avoid slang, and avoid expressing personal feelings around a <\/span>client\u2019s progress<\/span>, whether that\u2019s frustration or pride.\u00a0<\/span><\/span><\/p>\n

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3. Back up your observations with clear evidence.\u00a0<\/span><\/h3>\n

You should show the reasoning behind subjective observations \u2013 if you say a patient presents with low mood, include clear markers of their affect, body language, or self-reported condition.\u00a0<\/span><\/p>\n

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4. Double-check information like date, time, place, and diagnostic code.\u00a0<\/span><\/h3>\n

Progress notes<\/span> should act as an accurate and up-to-date record of the session, so these minor-seeming details are important. And if you need to change something…<\/span><\/span><\/p>\n

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5. Record any corrections formally.\u00a0<\/span><\/h3>\n

As these are official documents, you can\u2019t make edits that alter the initial record like crossing words out or deleting them if you\u2019re working digitally. There\u2019s an accepted protocol for correcting errors:\u00a0<\/span><\/p>\n